“The Best ED in the World” – Forgive Me -By Dan Pitt

Forgive me ACEM for I have sinned. It has been four hours since my patient arrived and a breach is inevitable. Oh, and I’ve never confessed before. But I need to now. I need to confess that I have been tempted by another. I have faced seduction by a calmer specialty. By the promise of daylight outside the window during my shifts. By the satisfaction of tubing a difficult airway in a controlled environment. A specialty in which I won’t be asked if I ever plan on specialising, despite having qualified. By a life free from four hour rules. And yes, of course, by the contractual obligation of regular coffee breaks. I need to confess that I have considered switching to anaesthetics.

I know I’m not the first, and surely I won’t be the last. It’s almost ironic that the very term our college requires of us, is the term most likely to convert us. Perhaps it’s a test. A threshold past which only the worthy progress… or the crazy. Perhaps, even now, having read this, my DEMTs are meeting to decide whether to have me offed in the night, or simply to eject me from the college. One of them keeps pet snakes, so if I wind up envenomated in your department, you know who to blame.

My contemplation surfaced on a recent stint in the anaesthetic field. Never having experienced this area, I found it fascinating. The complex interplay of medications and human physiology; the almost instantaneous response of vital signs to a hundred different parameters on the ventilator, or to minute changes in an infusion – I found it very cool. Not only that, but it was a department filled with many friendly and tremendously talented nurses and doctors. The end result was that it had me considering the switch. I’m not saying I had made up my mind. But I did leave anaesthetics with the distinct feeling that Emergency Medicine needed to prove itself to me once more.

It took only one night back in ED to do so.

“A night?” I hear you question. “Surely nights are the least likely of all shifts to bring you back to the light?”

Normally I would agree.

This night was a particularly busy one. Even at the start of the shift, the dreaded four hour mark had come and gone for many still in the waiting room. Fortunately, we had a crack team. Talented nurses, hard working SHOs, a fellow registrar whose enthusiasm I constantly try to emulate. It was not until several hours past midnight when we started to reach equilibrium – that merciful point at which the number of patients being picked up exceeds the number arriving.

Of course it’s that point, when you start to let down your guard and look towards the sunrise, that the unpredictability of emergency medicine usually strikes. Two patients to Resus in quick succession. One of them very sick, one of them extremely sick. The crack team assembled and we began to resuscitate. It was for the extremely sick patient that I called in the consultant. Or I would have, but for technological difficulties that prevented telephone contact. Several dial tones later and still no luck. We gained access and took bloods. We turned them green with radiation. We gave fluid and antibiotics and more lines and eventually inotropes. We began discussions with the family – half staunchly supportive of a palliative approach, half firmly opposed. We were confident but not comfortable – this was a patient who needed senior input.

I decided to wake up a consultant who was not on call and was met with a sympathetic ear and given some good advice. By this point the technological difficulties had abated and I was told that the on call consultant was on the way in. A short time later and the code alarm went off. CARPARK flashed on screens around the department. Our consultant, having arrived, had pressed the buzzer, seeking assistance. He had driven in behind an erratic car, parked behind it, and found somebody without a pulse in the back seat. We scooped the person from the car, deposited her on a trolley and commenced CPR in the carpark.

So yeah, all in all it was a busy night! But when the dust settled, I returned to a department that was still running smoothly because of hard working and tenacious residents. And at handover we once more felt that peculiar mix of relief and frustration. Relief that the department is still in one piece. And frustration that it looked as though we’d had an easy shift.

I don’t know whether I work in the “best ED” in the world, or perhaps even what constitutes “the best ED”, but I think I work in a great one. That night was a stressful mess, but I left feeling invigorated. Maybe it was the fiery enthusiasm of my fellow night registrar when it felt like we were beginning to drown. It could have been the friendly words of a boss who was not on call, and had every right to be grumpy. Perhaps it was the adrenaline of performing CPR while being wheeled on a trolley through the carpark. Or even the reassurance provided by experienced emergency nurses when self-doubt niggles at your decisions.

I think at the end of the day (or night), the measure of a great department is the relationships and experiences it fosters. Amongst doctors and nurses, physios and OTs and social workers, and admin staff always vigilant and helpful when I cannot work the fax machine. These are the things that make a great department. These are the things that remind my why I have chosen this often seemingly thankless profession.

I don’t know if I work in the best ED, but I must work in a great one – after all I keep coming back for more.